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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
itenwpin Minnesota Statutes.Chapter 103/ or W-series No.
(Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm. I Ig.) Date Sealed Approximate Date Well
Orono 117N 23W 21 W NW„NW„ 6/793 or Boring Constructed
Numerical Street Address
oorr'Fire
{,Number and City of Well or Boring Location
2540 Old Beach Road Depth Before Sealing 225 It Original Depth ft.
Show exact location of well or boring Sketch map of well or boring Static Water Level Accurate
in section grid with"X'. location,showing property lines.
N roads,and buildings. ❑Approximate
85 X
LTSingle Aquifer ❑Multiaquifer ft - below above land surface
I 1 I I
CASING TYPE
W E
T
i I I I Leel El Plastic El Tile El Other
mile
S Screen from to ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
❑Obstruction ❑Debris ❑Fill
PRtU&RT IlaWl NAM
Mailing Address it Type of debris/obstruction
different than property address indicated above. �- -
2540 Old Beach Road Obstruction/Debris/Fill removed? ❑Yes ❑No
Orono, M 55 1 PUMP
(j Removed ❑Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring.
3 in.from to ff. ❑Yes ❑No ❑Yes ❑No EgUnknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
9 No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
t
i in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
L_
❑Other
GROUTING MATERIAL �,.,,,�♦
Grouting material Neat CErent from 225 to _0 ft. yards 7 bags
from to ft, yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on properly? Yes ❑No in use
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
true to the best of my knowledge.
27194
C-A,a-o-r-u-in-e�same License or Registration No.
5/7/93
Authorized Representative Signature Dat
Thows Stelens 6/7/93
LOCAL COPY I„+ 2 Q 91 O
L Q Name o/Person Sealing Well or Boring
HE-01434-01